CORR Insights®: Is There an Association Between Insurance Status and Survival and Treatment of Primary Bone and Extremity Soft-tissue Sarcomas? A SEER Database Study

Where Are We Now?

The US healthcare financial system is a complicated maze of government and insurance regulations. Put simply, most veterans and people older than 65 years of age are covered by government-provided insurance. The majority of Americans 64 years of age and younger obtain insurance through their employer either directly or as a family plan. The remainder of the population in the United States qualifies for Medicaid, the Children’s Health Insurance Program (CHIP), purchases insurance through the exchanges (via the Affordable Care Act [ACA]), or is uninsured. To qualify for Medicaid, a family and/or an individual must have a very low income. The income levels and disabilities for qualification vary by state. In the 36 states that have expanded Medicaid by accepting federal dollars for the program, the income level for qualification increases and the number of uninsured people decreases correspondingly. Those that do not qualify for Medicaid and do not have employer-based coverage, or another source of insurance represent the majority of millions of uninsured Americans (27.4 million, in 2017) [3].

In the current study, Smartt and colleagues [8] used data from the Surveillance, Epidemiology, and End Results (SEER) database to investigate cancer-related outcomes of patients with bone or soft-tissue sarcomas stratified by insurance status. This study provides an interesting snapshot into the complicated US healthcare system by focusing on outcomes of these rare diseases [1]. The authors looked at three important clinical outcomes in patients with a bone or soft-tissue sarcoma: (1) Presence of metastasis at the time of diagnosis; (2) rates of limb salvage compared to amputation; and (3) death related to cancer. The authors then correlated those cancer-related outcomes to insurance status and found that a patient with Medicaid who is diagnosed with sarcoma is more likely to present with metastases, have an amputation, and/or die of their disease compared to patients with non-Medicaid insurance. Their findings support those of other cancer-related outcome studies [1, 2].

Where Do We Need To Go?

For patients with a sarcoma, good care is defined by early diagnosis (prior to developing metastatic disease), high disease-specific survival rates, and limb salvage whenever appropriate; obviously all patients, regardless of insurance, deserve and should receive good care. While the current study uses insurance status as a proxy for poverty and disparities in care for sarcomas, it does not provide a pathway to minimize disparities in care that can impair our ability to provide good care as I’ve defined it. To do so, we should focus on: (1) Access to care and (2) healthcare system improvements.

Access to care is worse for patients who have Medicaid or for those who are uninsured in part because some of these patients may be ineligible for Medicaid until a cancer diagnosis is made (since that is considered a qualifying event). That being so, the first step in improving access is closing the uninsured gap in our present system. The next steps are more complicated, and often are confounded by a number of societal barriers (distance to providers or experts, family medical leave issues, and poor family support system) or system-based roadblocks (need for authorizations, approvals, referrals; narrow networks, or copay charges).

While having Medicaid improves access to care, one should not equate having Medicaid with having full access to good health care. The patchwork of non-Expansion Medicaid plans, each unique to its state boundaries, leaves enrollees in narrow networks often without access to specialists, imaging, or advanced treatment modalities such as chemotherapy and radiation therapy. Medicaid plans in states that have expanded Medicaid under the ACA provide a uniform level of coverage to patients as required by the law. Enrollees in Medicaid expansion states are primarily the working poor, considered those with too much income to qualify for Medicaid but not enough income to qualify for the ACA marketplace plans. These patients would be the uninsured and newly enrolled in Medicaid in the current study [8]. The uneven expansion of Medicaid across the states has set up a natural experiment to see if broader coverage as required by the ACA and improved access to care before a cancer diagnosis will change cancer related outcomes for Medicaid recipients.

It is particularly alarming that the frequency of amputation for patients with Medicaid enrolled patients with bone sarcomas was greater than insured patients (21% for Medicaid patients compared to 13% for non-Medicaid) [8]. The potential reasons for a higher amputation rate could include increased tumor size due to delay in diagnosis, insufficient adjuvant treatments (radiation and/or chemotherapy), lack of referral to limb salvage specialists, or other reasons. We need further investigation to understand by the amputation rate is higher in this population.

How Do We Get There?

Our responsibility as healthcare providers is to help alleviate the barriers to care that have resulted in poor cancer-related outcomes as highlighted by this report. We should work on public policy that increases the numbers of our population that are insured to improve access to care. Medicaid expansion, universal health care, or other plans to cover the entire population need to be implemented to attain this goal. We must recognize the impact of poverty on healthcare outcomes and make progress to mitigate these effects. Now more than 5 years since the implementation of the ACA, we are beginning to see differences in a number of domains between Medicaid expansion states and non-expansion states. Infant mortality, maternal mortality, and overall mortality have improved in expansion states compared to non-expansion states. Studying the effects of Medicaid expansion could help guide public policy. We should analyze the cancer related outcomes of patients with sarcomas in states prior to and after Medicaid expansion. This well-conducted study of the SEER database should be repeated comparing 2015 to 2018 data of expansion states versus non-expansion states to determine whether there is a difference in clinical outcomes for a rare disease process like sarcomas.

Grimer showed in the UK population of the NHS that early referral to sarcoma centers could mitigate delays in care and improve patient survival and limb salvage [4-7]. Their published guidelines for diagnosis and referral of bone and soft-tissue tumors results in earlier referral to sarcoma centers where coordination of care is improved, and limb salvage rates increase. Removing barriers, speeding referral, and improving coordination of care should be included in our goals. To further understand this vulnerable population, we should study the time from onset of symptoms to obtaining definitive care, the completeness of therapies, and correlate these factors with presentation with metastasis, disease specific survival, and frequency of amputation.

To improve limb salvage rates in this disadvantaged population, we need to gain further understanding of the root causes of this higher rate of amputation. To validate whether this is an insurance status issue that limits ready access to tertiary care centers, frequency of amputation at large tumor centers could be compared to the frequency at smaller community based practices. The proportion of patients who receive adequate adjuvant therapy completion and the time to diagnosis and tumor size in this patient population should be investigated.

I applaud the authors for highlighting poorer survival and lower limb salvage incidence experienced by patients with Medicaid in the United States. While the findings are disturbing, they provide a path to public policy change, practice improvement, and future investigation.